Absent Owner Authorization Form

Date

Name

FirstLast

Pet(s) Name(s)

I authorize to make emergency veterinary medical decisions for pets described above, in the event that I cannot be reached. Where Applicable, I have also listed guidelines and limitations of care. I understand that as owner, I am responsible for any financial costs for the veterinary care provided to my pet(s).

Authorized agent's name

Contact information in case of an emergency

Phone Number

Email

Alternate Phone Number

Other

Authorized Agent's name and phone number

The authorized agent is responsible for my pet(s) (please check one)

Only during the time frame indicated.

Anytime I am unable to bring my pet(s) to your facility

Departure Date & Return Date

Please check all boxes that are applicable

I authorize emergency veterinary care costs

I grant the authorized agent the ability to make all veterinary medical decisions including euthanasia